Tuberculosis still a public health menace

As one of Nepal’s worst health problems, tuberculosis (TB) kills between 5,000-7,000 Nepalis every year, according to Ministry of Health. The ongoing insurgency against Maoist separatists has made effective treatment and prevention of the disease problematic, but has not deterred national anti-TB programmes, health workers say. Despite this, health experts say that the TB mortality rate would be much higher if not for the National Tuberculosis Programme (NTP) run by the government’s National Tuberculosis Centre (NTC), with technical and financial assistance from a consortium of international health agencies. “Today we are able to save the lives of 80,000 people, because this is the number of people with active TB,” Christian Gunnberg from the UN’s World Health Organization (WHO) told IRIN. The world health body is one of the government’s main partners in the TB programme, providing technical support and helping in staff training and research. Efforts to control and reduce TB have been helped by the Directly Observed Treatment Short (DOTS) course scheme, the internationally recommended TB control strategy. Introduced in 1996, the same year that the Maoist’s armed struggle was launched, DOTS has now been implemented in all 75 districts around the country where 40,000 new TB cases are added every year. “I lost my grandfather because he did not know where to go for treatment,” said 18-year-old Sabita Nakarmi whose 50-year-old relative died of tuberculosis. Now, 15 years after his death, Sabita herself has become infected with the same disease but the eight-month DOTS programme helped to cure her completely. “I am lucky that I survived. I only wish that such treatment was available then to cure my grandfather.” Despite the conflict situation, the DOTS scheme is available in more than 2,500 treatment centres and sub-centres across Nepal. But now, insecurity, road blocks, strikes and clashes between security forces and rebels mean there are serious concerns about whether TB patients are able to reach health centres to get their TB medicine. Those being treated for the disease have to take medicines on a daily basis for the first two months in front of trained health workers. The medication does not work if there are gaps in the treatment. “Access to DOTS, as for all healthcare, is a fundamental right for all citizens. Therefore the provision of services and people’s access to them should be protected, respected and promoted by all concerned in this conflict,” Susan Clapham from the UK’s Department for International Development (DFID) told IRIN in Kathmandu. DFID supports the national TB programme by providing anti-TB drugs through the WHO. In 2004, it helped to provide medicine worth nearly US $7 million. Clapham explained that the NTP is highly valued by the community and patients continue to attend for their treatment, despite the current security climate. “Over the last few years the conflict has escalated. However, the NTP’s data does not reveal a significant impact on service availability and service utilisation,” Clapham said. Health professionals involved in combating tuberculosis are happy that even those families displaced due to the conflict generally manage to continue the DOTS programme as treatment is available in many places in the country and the medicines are totally free. “The DOTS system is so effective that wherever people are displaced, they can easily find a centre to help them. Besides, they always carry their tuberculosis report, so it will be easy for the doctor to make their medication consistent,” explained Nem Mitra Shrestha from the German Nepal Tuberculosis Project (GENETUP), which runs one of the most highly regarded DOTS centres in the country. The national TB programme of Nepal has already been regarded as very successful both nationally and internationally. The treatment success rate has more than doubled from 40 percent in 1994 to over 88 percent currently. “Tuberculosis treatment programmes work well when properly thought through, well-designed and when treatment centres and diagnostic services are placed close to the patients,” Keshab Bhakta Shrestha, director of the NTP, told IRIN. Shrestha added that a new programme, ‘DOTS-Plus’, is being added in May to treat those patients with multi-drug resistant-TB (MDR-TB), which is one of the leading causes of death among TB patients in Nepal. Untreated TB tends to kill when complicated by other diseases like HIV/AIDS, leukemia, cancer, and lung and heart diseases. Experts said that MDR-TB occurs when patients fail to take regular medication or are given wrong drug prescriptions by doctors. According to government estimates, around 500 patients develop MDR-TB every year. Currently, the NTC is working closely with international health agencies to introduce accessible drugs for MDR-TB treatment, but they are very expensive. Treatment for one patient would cost nearly $1,000. Nepal’s success stories in combating tuberculosis has already attracted a large number of international donors and the government has categorised the TB programme as a high development priority. Over 14 key agencies from Germany, the UK, Japan, the Netherlands, Norway and France have been actively participating in the national programme. “Nepal’s TB programme has adopted a commendable public health approach, which addresses social dynamics in its delivery. For example it has decentralised care provision right down to sub-health post [basic village medical facility] level. In addition to the fact that front health workers provide care, so do trained community volunteers,” explained DFID’s Clapham. “This ‘de-medicalisation’ of the disease is a critical learning point not just for TB. We can apply this to other health programmes within Nepal, as well as in other South Asian countries,” she added. According to the WHO, TB is primarily an illness of the respiratory system, spread by coughing and sneezing. Each year about 2 million people die worldwide from this otherwise curable disease.